Neonatal outcome of second-stage cesarean delivery versus vacuum extraction among neonates <34 weeks

Objective: Among deliveries <34 weeks, there is inconclusive evidence regarding the preferred route of delivery when there is a need to expedite delivery during the second stage of labor. As it is unreasonable that future randomized controlled trials will be conducted to settle this query, every clinical data concerning this topic, may be helpful. We aim to compare neonatal outcomes among women undergoing emergent cesarean delivery (ECD) versus vacuum-assisted delivery (VAD) during the second stage of labor among singleton gestations <34 weeks. Methods: A retrospective cohort study including all women who underwent either ECD or VAD at the second stage of labor between 30°^/7 and 33^6/7weeks, during 2011–2019. The primary outcome was the rate of adverse neonatal outcomes, defined as intrapartum death, mechanical ventilation, asphyxia, respiratory distress syndrome, subgaleal hemorrhage, intraventricular hemorrhage, necrotizing enterocolitis, and phototherapy. Results: Of the 153,672 live singleton deliveries during the study period, 2871 (1.9%) delivered before 34°^/7. Of those 1674 (58.3%) delivered vaginally unassisted and 1137 (39.6%) delivered by a CD during the first stage of labor. A total of 60 deliveries were analyzed, with a median gestational age of 32 weeks, interquartile range (IQR) 31–33. Median birth weight at delivery was 1845 g, IQR 1574–2095. Overall 25 (42%) of women were delivered by VAD and 35 by CD (58%). Indications for expeditious delivery did not differ between the study groups. Neonates delivered by VAD had a higher median birth weight (1940 vs. 1620 g, p =.02). Second stage of labor was longer in the ECD group as compared to the VAD group (median 200 vs. 52 min, p =.01). The rate of Apgar score at 1 min <7 was higher among the CD group (10 (40%) vs. 5 (14%), OR [95% CI]: 4.0 (1.1–13.8), p =.03). Longer length of stay was evident in the CD group as compared to the VAD group (median 30 vs. 21 days, p =.001). The rate of composite neonatal adverse outcome was comparable between the study groups. Adverse outcomes were associated with lower body mass index (median 27.7 vs. 34.9, p =.04), higher rate of premature preterm rupture of membranes (40 (91%) vs. 5 (31%), OR [95% CI]: 22.0 (5.0–91.1), p <.001) and labor dystocia as the indication for expedited delivery (38 (86%) vs. 7 (44%), OR [95% CI]: 8.1 (2.1–30.1), p =.001). Conclusions: Cesarean delivery during the second stage of labor of gestations <34 weeks was associated with a higher rate of lower Apgar scores and longer length of stay. Synopsis: Delivery by second stage CD of premature neonates <34 weeks is associated with a higher rate of lower Apgar score.